System, method, and computer program for interfacing an expert system to a clinical information system

ABSTRACT

A method and computer program for interfacing an expert system to a clinical information system. Embodiments of the invention provide tight integration of the systems permitting a clinician to use the functionality provided by the expert system without specifically maintaining separate patient data. They provide a method for communication between the expert system and one or more clinical information systems. This communication permits flow of information and actions between the expert system and the clinical systems and allows maintenance of audit logs in both systems.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.10/773,106, filed Feb. 5, 2004 now U.S. Pat. No. 7,230,529, which claimsthe benefit of U.S. Provisional Application No. 60/445,889, filed Feb.7, 2003. Both applications are herein incorporated by reference in theirentirety.

BACKGROUND OF THE INVENTION

1. The Field of the Invention

This invention generally relates to facilitating communication between aclinical system and a separate expert system. More specifically, thepresent invention relates to systems, methods, and computer programsthat provide an interface between a clinical system and a separateexpert system.

2. The Relevant Technology

Clinical information systems and electronic medical records systems havebeen used in patient care for many years. These systems contain adatabase or repository of data related to the users and administrativefunctions of the system, as well as a history of clinical results andactivities (clinical data functions). They are used as a medical record,for financial transactions related to care, and as a tool for theongoing clinical treatment of the patient. However, historically, thesesystems have been built as Online Transaction Processing (OLTP) systems.As a result, they do not contain a great deal of medical or scientificknowledge, and are not designed to provide expert recommendations, (i.e.perform expert functions).

Some clinical information systems have been built with alertingmechanisms and rule-based event monitors embedded within them to provideexpert recommendations based on clinical data entered in the system.These systems do not require specific system interfaces betweendifferent modules performing the clinical data functions and the expertfunctions because the clinical data functions and expert functions areembodied in a common system. The need for rapid processing oftransactions has limited the power of this model, and in turn haslimited the type of expert advice which can be generated. In addition, auser is limited to the features provided by the specific expert systemembedded within the common system that has been developed or purchased.There is no opportunity to combine a different expert system within theclinical system itself.

Online Analytic Processing Systems have been developed to provideoptimal analytic expert functions. However, these are separate fromclinical systems, and while they may have inbound data connection fromclinical systems to populate their databases, there is no flow ofinformation back to the clinical system, nor is there an interactivemechanism between the two systems which allows users to move seamlesslybetween the two types of functionality. These systems are generally usedfor administrative or case management purposes, rather than directclinical care. The knowledge embedded and the recommendations made arenot directly actionable.

Expert systems have been developed as stand-alone systems, and have beenshown to provide valuable information that has the potential to improvemedical care. However, their separate nature has limited theirusefulness as well. Systems that require the user to enter a separateapplication are less likely to be used, and those that require the userto enter clinical information that already resides in clinical systemsplace an additional burden on the user. In addition, they risk loss ofdata fidelity (or accuracy) because reentered data may be incomplete orin error. The separate nature of these stand-alone systems has thuslimited their usefulness and their adoption in clinical practice.

Stand-alone expert systems have not been integrated into clinicalsystems for a number of reasons. First, comprehensive Electronic MedicalRecord (EMR) systems are found in very few health systems. Those fewsites that have such Electronic Medical Record systems have oftendeveloped them in house, and have developed decision support and expertsystems within the Electronic Medical Record system itself.

Separate expert systems have been developed for a number of focusedclinical areas, but without an Electronic Medical Record system inplace, integration was not possible. In addition, there are manytechnical barriers to an integrated system. First, many ElectronicMedical Records have been developed with proprietary operating systemsand databases. These systems are difficult if not impossible tointegrate with unrelated systems. Second, there is a lack of standardsfor data and knowledge representation. This makes it difficult totransfer data that could be properly interpreted and manipulated. Evenwith interface standards that define the structure of messages betweensystems, the content of the messages may be useless without a commonvocabulary.

Commercial systems have also not been developed which integratestand-alone expert systems with clinical Electronic Medical Records. Thebusiness model of Electronic Medical Record vendors is to providecomprehensive solutions to health systems. They differentiate themselvesby virtue of the functionality in their expert systems. These systemsare integral to their products, and they are not developed to work withthe Electronic Medical Record of another vendor. This has discourageddevelopment of independent expert systems that are designed to integratebroadly. Vendors of small niche expert systems have focused on specificareas of functionality such as case management, insurance certificationof appropriateness of care, and data analysis. Direct care clinicians donot generally use these systems, and so integration with the ElectronicMedical Record has not been pursued.

Finally, the conventional wisdom and teaching of the medical informaticsliterature has discouraged separate expert systems. Because of theproblems with performance, security, vocabulary inconsistencies, andcontrol over development, the widely stated belief has been that expertsystems can only be effective when they are built directly into clinicalsystems. The result of this teaching has been to encourage thedevelopment of expert systems that are built into clinical systems, andno attention has been paid to developing a system or method to permit anindependent expert system to function in an integrated fashion.

BRIEF SUMMARY OF THE INVENTION

The present invention generally relates to systems, methods, andcomputer programs that integrate a stand-alone expert system with one ormore independent clinical systems. This method allows the stand-aloneexpert system to be developed and executed independently, and to then beintegrated with one or more clinical systems via a set of definedinterfaces. There is at least one interface directed into the expertsystem, and one interface directed out of the expert system to theclinical system. The method allows the expert system to have access toclinical data without requiring separate input by users, and thuspreserves data fidelity. It also allows the user to access the expertsystem from within each of the clinical systems to which it maycommunicate, and provides seamless movement between the systems.Functionally, the expert system behaves as if it is built intrinsic tothe clinical system, although it is actually independent. Thiscomplements the clinician's existing workflow, and increases thelikelihood that clinicians can use the expert system.

One embodiment of the present invention includes a system forfacilitating communication between a standalone medical expert systemand at least one clinical system, the system including a standalonemedical expert system remote from the clinical system. Without thepresent invention, the expert system communications may be incompatiblewith the clinical system or one of its associated clinical modules.Communicating with the expert system and the clinical system is at leastone interface module that facilitates transmission of the data betweenthe expert system and the clinical system. The interface module(s) alsoenable a user of the clinical system to seamlessly access and use thefunctionality of the medical expert system from within a user interfaceof the clinical system, with the expert system at least partiallycontrolling the functionality of the clinical system. By so doing, aclinician, physician, or technician uses a clinical module, such as butnot limited to, a CDR module, an ADT module, a laboratory module, apharmacy module, a radiology module, or Electronic Medical Recordmodule, that can access the independent and separate expert systemwithout manually switching applications, re-entering data, or otherwisehaving the graphical user interface presented by one or more of theclinical modules or the clinical system.

In another embodiment of the present invention, at least one interfacemodule includes or functions as one of a variety of differentinterfaces, such as but not limited to, an Inbound Data Interface, anOutbound Alert Interface, Outbound Order Interface, Outbound DataInterface, Inbound Application Interface, a Synchronous Alert Interface,or an Audit Action Interface.

These and other advantages and features of the present invention willbecome more fully apparent from the following description and appendedclaims, or may be learned by the practice of the invention as set forthhereinafter.

BRIEF DESCRIPTION OF THE DRAWINGS

To further clarify the above and other advantages and features of thepresent invention, a more particular description of the invention willbe rendered by reference to specific embodiments thereof that areillustrated in the appended drawings. It is appreciated that thesedrawings depict only typical embodiments of the invention and aretherefore not to be considered limiting of its scope. The invention willbe described and explained with additional specificity and detailthrough the use of the accompanying drawings in which:

FIG. 1 illustrates a schematic diagram of one exemplary embodiment ofthe present invention, representing one model of interfaceimplementation between a clinical system and an expert system;

FIG. 2 illustrates a workflow diagram illustrating a use of the systemshown in FIG. 1;

FIG. 3 illustrates a workflow diagram of an alternative use of thesystem shown in FIG. 1;

FIG. 4 illustrates a schematic diagram of another exemplary embodimentof the present invention, representing another model of interfaceimplementation between a clinical system and an expert system;

FIG. 5 illustrates a workflow diagram illustrating a use of the systemshown in FIG. 4;

FIG. 6 illustrates a workflow diagram illustrating another alternativeuse of the system shown in FIG. 4;

FIG. 7 illustrates a workflow diagram illustrating yet anotheralternative use of the system shown in FIG. 4;

FIG. 8 illustrates a schematic diagram of another exemplary embodimentof the present invention, representing yet another model of interfaceimplementation between a clinical system and an expert system; and

FIG. 9 illustrates a workflow diagram illustrating a use of the systemshown in FIG. 8.

DETAILED DESCRIPTION OF THE EXEMPLARY EMBODIMENTS

Referring now to FIG. 1, a Clinical System (CS) 101 includes, in oneexemplary embodiment, a number of clinical modules including a ClinicalData Repository (CDR) 102, an Admission, Discharge, Transfer (ADT)system 103, a laboratory (LAB) system 104, a pharmacy (PHARM) system105, a radiology (RAD) system 106, an Electronic Medical Record (EMR)107, and a Clinical System Interface Engine (CSIE) 108. The clinicalmodules of the Clinical System 101 shown in FIG. 1 are not exhaustive,nor are all the clinical modules required for embodiments of the presentinvention. Rather, the modules, systems, interfaces, and databases shownin FIG. 1 are illustrative of one exemplary embodiment of the invention.The clinical modules may be themselves clinical systems as that term isunderstood in the art. Thus, as used herein, a clinical system may referto individual clinical modules or to a collection of clinical modules.

Each of the clinical modules may include a user interface (UI) 116 thatdisplays information to a user and accepts data input from the user. Theinformation displayed may be stored, for example in the Clinical DataRepository 102, or in one of the clinical modules to which theinformation applies. Similarly, data input through the 116 is directedto the Clinical Data Repository 102 or to a repository at a clinicalmodule to which the information applies. The UI 116 can be one of avariety of graphical user interfaces that provides visualrepresentations of the data and allows additional data to be input orentered into the Clinical Data Repository 102. Various frames, fields,menus, images, and text may be used as part of the UI 116.

The Clinical System Interface Engine 108 receives feeds of data 110,111, 112, 113, 114, 115, from each of the clinical modules. In turn, theClinical System Interface Engine 108 provides the data to the ExpertSystem 119. These feeds of data 110, 111, 112, 113, 114, 115, may beperiodic, sporadic, or continuous feeds. In an alternate embodiment ofthe invention, a clinical system interface that performs thefunctionality of the Clinical System Interface Engine 108 may beimplemented as a part of one of the clinical modules. Thus, a clinicalmodule, in such case, can send and receive data directly to and from theExpert System 119. One example of this is shown in FIG. 1 where the UI116 of the Electronic Medical Record 107 is connected directly to theExpert System Interface Engine 125.

An Expert System 119 exists as a separate system from the ClinicalSystem 101. The Expert System 119 may include an Expert System UserInterface (ESUI) 123, an Expert System Database (ESDB) 124 and an ExpertSystem Interface Engine (ESIE) 125 interconnected by various data feeds120, 121, 122. The Expert System 119 is connected to the Clinical System101 through the Clinical System Interface Engine 108 using variousinbound and outbound data interfaces or feeds 130, 131, 132, 133, 134,135, 136. The data interfaces or feeds have specific formats and datastructures that define how and what data can pass through the datainterface or feed. For instance, and not by way of limitation, the datapassing through the interface or along the data feed may have specificheaders, specific patient information elements, alert elements, orderelements, and the like. These data interfaces or feeds will be discussedin individual detail below.

These various interfaces enable communication between an Expert Systemand a Clinical System, and/or the clinical modules associated with theClinical System. These interfaces provide a structured manner by whichdata is bi-directionally communicated between the Clinical System, andthe associated clinical modules, and the Expert System. Followinghereinafter is a discussion of the exemplary interfaces associated witha Clinical System Interface Engine and an Expert System InterfaceEngine. In one embodiment, the interfaces may utilize industry standardmessage definitions, with such definitions being added to and modifiedto create the interface definitions described herein. Other embodimentsof the invention allow for the use of proprietary message definitions.Proprietary message definitions, as well as industry standarddefinitions, can be used to ensure agreement in structuring messagestransferred between an Expert System and a Clinical System.

As shown in FIG. 1, the Clinical System Interface Engine 108 and the

Expert System Interface Engine 125 can communicate via an Inbound DataInterface (IDI) 133. This interface provides a conduit and messagestructure for transferring data regarding individual patients where thatdata has been input into the clinical modules of the Clinical System101. These clinical modules can include, but are not limited to,Admission/Discharge/Transfer (ADT), laboratory (Lab) systems, pharmacysystems, orders systems, radiology systems, clinical documentationsystems, clinical repositories, and other interface engines.

The following tables include illustrative data elements for specificInbound Data Interface types. The following is only exemplary and otherdata elements may be used within the scope of embodiments of the presentinvention. Some embodiments implementing industry standard messagedefinitions may include additional definitions, such as Z or other HL7defined segments, which can be added for any interface transaction type.

TABLE 1 ADT segments MSH Message Header EVN Event PID PatientInformation MRG Merge [{NK1}] Next of Kin PV1 Patient Visit [PV2]Additional Patient Visit [{DG1}] Diagnosis [{GT1}] Guarantor [{IN1}]Insurance [ACC] Accident

TABLE 2 Lab Segments MSH Message Header PID Patient Information {[NTE]}Comment [PV1] Patient Visit [ORC] Common Order OBR Order Detail {[NTE]}Comment {[OBX]} Observations/Results {[NTE]} Comment

TABLE 3 Pharmacy Segments MSH Message Header PID Patient Information PV1Patient Visit ORC Common Order Information RXR Pharmacy Route {RXE}Pharmacy Encoded Order [AL1] Allergy information [{OBX}] PatientHeight/Weight

TABLE 4 Radiology Segments MSH Message Header PID Patient IdentificationPV1 Patient Visit ORC Order Common OBR Observations Report ID {[NTE]}Notes and Comments {[OBX]} Observation/Results

TABLE 5 Blood Gas (ABG) Segments MSH Message Header PID PatientInformation ORC Common Order Information OBR Observations Report ID{[OBX]} Observations/Results

TABLE 6 Text (transcription) Segments MSH Message Header PID PatientIdentification PV1 Patient Visit OBR Observation Request {[OBX]}Observation/Result

FIG. 1 illustrates the Expert System Interface Engine 125 sendingmessages on the Outbound Alert Interface 131 to the Clinical SystemInterface Engine 108. An Outbound Alert Interface provides a conduit andmessage structure for transferring alert information for specificpatients from an alert generated by an Expert System. Asynchronousalerts generated within the Expert System can be sent in a message to anexternal Clinical System. This can be displayed in the external system'suser messaging application. The external system can provide a mechanismto link to the Expert System and access the alert content directly. Thecontent of the message may include one or more of the following:

-   -   1. Target user identifiers. The Expert System may identify a        specific user who is the target of the alert.    -   2. Patient identifiers.    -   3. Alert session identifier.    -   4. Date/time stamp.    -   5. Alert identifier or name.    -   6. Alert message. This message can contain the reason the alert        fired and a recommendation to use the Expert System to act on        the alert.    -   7. Some identifier which the external system can use in a link        utilizing the Inbound Application Interface to present the        appropriate alert to a user directly when the Expert System is        entered through the external application.    -   8. Urgency indicator. This indicated the urgency of the alert to        the external system.    -   9. Update indicator. Sent concerning a previous alert, capable        of updating the alert in the external system or of indicating        the alert can be removed.

FIG. 1 illustrates the Expert System Interface Engine 125 sendingmessages to the Clinical System Interface Engine 108 on the OutboundOrders Interface (OOI) 135. An Outbound Orders Interface provides aconduit and message structure for transferring orders for a specificpatient from an Expert System to a Clinical System. This interface cancarry medication orders to an external system such as a pharmacyinpatient, pharmacy retail, or order management system. It may alsocarry orders for laboratory studies, radiology studies, or otherclinical orders to be directed to the appropriate system. The orders maybe sent to an order scratchpad, or equivalent area, of the externalsystem so that the order can be processed from there. Alternatively,such orders may be sent directly to a pharmacy or other departmentalsystem.

Both patient and user context may be passed by the OOI. This interfacecan carry order details. User comments, reject reasons, and relatedinformation are sent via the Audit Action Interface (described in moredetail below). The content of the message may include one or more of thefollowing:

-   -   1. User identifiers.    -   2. Patient identifiers.    -   3. Alert session identifiers.    -   4. Date/time stamp.    -   5. Alert identifier.    -   6. A list of orders and order actions. The reply can support one        or more different orders.    -   7. Order details for each order in the list. This can use, for        example, proprietary message definitions or industry standard        message definitions such as the HL7 order interface standard.    -   8. Supported actions can include new orders, discontinue,        hold/suspend, modify, and any other actions defined in the        proprietary message definitions or industry standard message        definitions.    -   9. Order identifier. This is an identifier from the external        system that identifies a specific order instance in that system.        It is needed to discontinue, modify, or take any other action on        an existing order in the external system.

FIG. 1 illustrates the Expert System Interface Engine 125 sendingmessages to the Clinical System Interface Engine 108 on the OutboundData Interface 134. An Outbound Data Interface provides a conduit andmessage structure for transferring data entered into the Expert Systemby a user or generated within the Expert System to the external system.This may be discrete, structured elements such as height or vital signs,or a document such as physician exam components, completed online roundsreport, or a decision-supported progress note. For example, when the HL7specifications are used, there can be one interface with separate HL7OBX segments for data elements and for a document itself Patient anduser context may be passed. The content of the message can include:

-   -   1. A proprietary message or industry standard message such as an        HL7 OBR message, sent as, for example, an XML document. It may        be implemented with the same elements as in the inbound data        interfaces. This message may contain the identifiers for the        data elements sent as well as the values for these elements.        These elements may include for example, patient, date, time,        nature of the data element, and origin.    -   2. Alert identifiers.    -   3. Alert session identifiers.    -   4. A proprietary message or industry standard message such as an        HL7 allergy message may be used to send allergy information.    -   5. A proprietary message or industry standard message such as an        HL7 diagnosis message may be used to send problem or diagnosis        information.

FIG. 1 illustrates the Expert System Interface Engine 125 receivingmessages from the Clinical System Interface Engine 108 on the InboundApplication Interface 132. An Inbound Application Interface provides aconduit and message structure for providing access to an Expert Systemfrom a link within an external system such as a Clinical System. Thelink determines the component of the Expert System that is accessed. Theinterface can contain all data needed by the Expert System, such as adrug or result that is in question. Patient and user context aremaintained. If the link is present in the external system because of analert generated in the Expert System, the interface message can containan identifier to connect to that alert content in the Expert System. Thecontents of the message may include for example:

-   -   1. User identifiers.    -   2. Patient identifiers if present.    -   3. Alert session identifiers if relevant.    -   4. Date/time stamp.    -   5. Indicator of what part of the expert system to open.    -   6. Context for the link. If it is in a medication order, the        message can contain the medication and associated order details.        The message can also contain any patient information not        expected to already be in the expert system.    -   7. Drug information, including drug, dose, route, frequency,        duration, etc.    -   8. Lab information including lab tests, result value, interval        of testing, etc.

FIG. 1 illustrates the Expert System Interface Engine 125 sending andreceiving messages to and from the Clinical System Interface Engine 108on the Synchronous Alert Interface 130. A Synchronous Alert Interfaceprovides a conduit and message structure for supporting a synchronousinteraction between an external system and an Expert System.Specifically, a Synchronous Alert Interface provides a message structureor protocol that allows an external system to request processing oforders or other clinical data by an Expert System so as to utilizefeatures of the Expert System such as an alert generator. In this way,an Expert System can be used to analyze an order that is placed in theexternal order management system, such as a Computerized Physician OrderEntry (CPOE) system, or a pharmacy system. The external system can callthe Expert System with a message containing the order(s) to be analyzed,and can hold further processing of the orders pending the Expert Systemreply. The Expert System reply can identify whether or not an alert hasfired. If an alert has fired, the reply can contain sufficientinformation to let the External System process the alert. This mayinvolve automatically making changes, or it may require the externalsystem to present the alert information to the user. The user can thendetermine whether or not to accept the recommendations. Once thisoccurs, the external system can communicate the outcome back to theExpert System for audit.

The Synchronous Alert Interface is a bi-directional interface. Theexpert system inbound interface of the Synchronous Alert Interface isfrom external system applications such as CPOE or a pharmacy order entrysystem. This is a request for processing by the Expert System alertengine. It contains patient and user context, as well as the specificsof the action being critiqued or analyzed. Because the present inventionutilizes an interactive session between the Expert System and a ClinicalSystem, it is desirable for the Expert System to have high performance.

The present invention supports synchronous interaction or communicationbetween the Expert System and the Clinical System. Actions taken in theClinical System are verified or analyzed in the Expert System and aresponse given by the Expert System to the Clinical System regarding theverification or analysis before the actions are completed or performedin the Clinical System. The reverse is also possible.

The Expert System outbound interface of the Synchronous Alert Interfacecontains the results of alert processing. If an alert is generated, thenthe alert contents with patient and user context are returned. If noalert is generated, then the reply so indicates. Audit informationpasses to a host system via the Audit Action Interface. This auditinformation transmission could be asynchronous.

The Expert System's processing of the present invention can be donewithout user interaction, and the reply is direct to the externalsystem. The external system determines whether to launch the ExpertSystem application directly or present the user with a link to theExpert System that allows the user to consult the Expert System. Theexternal system may present information from the Expert System's replywithin the external application, and allow user to accept or reject thisinformation. If this implementation is chosen, audit information can bereturned to the Expert System via the Audit Action Interface. Thecontents of the inbound message associated with Synchronous AlertInterface may include one or more of the following:

-   -   1. User identifiers.    -   2. Patient identifiers.    -   3. Alert session identifiers.    -   4. Date/time stamp.    -   5. List of orders with accompanying order details including        order identifier, ordering physician.    -   6. Other clinical information relevant to the order such as lab        results or allergy information.

The contents of the outbound message Synchronous Alert Interface caninclude one or more of the following:

-   -   1. User identifiers.    -   2. Patient identifiers.    -   3. Alert session identifiers.    -   4. Date/time stamp.    -   5. Alert flag to indicate whether an alert was generated.    -   6. List of additional orders with details.    -   7. List of orders to delete or change with details of changes.    -   8. An identifier the external system can use to allow the user        to link directly to the Expert System alert in the Expert System        if they want to interact with the Expert System to investigate        and act upon the recommendation.    -   9. The message can be structured to carry multiple alerts        triggered from one session.

FIG. 1 illustrates the Expert System Interface Engine 125 sending andreceiving messages to and from the Clinical System Interface Engine 108on the Audit Action Interface 136. Specifically, an Audit ActionInterface provides a message structure or protocol that allows anexternal system and an Expert System to keep their alert audit trailssynchronized. The external messaging system may allow a user to dismissan alert directly, and the Expert System needs to close out the audittrail on that alert. Alternatively, an external alert audit mechanismmay be updated to reflect the actions users take within the ExpertSystem. This also provides the external system a mechanism to presentthe outcome of an alert at later points in the patient care process whenthe issue arises again.

The Expert System inbound audit message contains action and overridereasons when an alert presented in an external system is acted upon byuser. This allows the Expert System to update its audit log when analert is dismissed from within external system.

The Expert System outbound audit message contains action and overridereasons when alert is acted upon within the Expert System, and allowsthe external system to maintain its audit trail.

The Expert System outbound audit message also allows external systems todisplay override reasons and other comments to additional users when thealert content is displayed to them. For example, if a pharmacistsubsequently views a physician comments on an alert, the pharmacist canalso view the physician's actions and stated rationale.

Override reasons can be codified to allow efficient search andstandardization of reasons where possible. However, the messagestructure can also support free text comments.

The interface is bi-directional, but the content of messages is the samein both directions. The contents of the message can include:

-   -   1. User identifiers.    -   2. Patient identifiers.    -   3. Alert session identifiers.    -   4. Date/time stamp.    -   5. Alert identifier.    -   6. Alert action.    -   7. Codified override reason.    -   8. User comments.

Generally, the Expert System of the present invention contains aknowledge base and a means or mechanism for holding patient information,such as hardware and/or software modules and components. The ExpertSystem can include an interface engine that receives data into theExpert System and transmits it back into one or more external clinicalsystems that can communicate with the Expert System using one or moreinterfaces. The Expert System can also include an inference engine thatpre-processes the incoming data, and one or more knowledge engines thatapply knowledge from the knowledge base to individual and populationpatient information.

The Expert System can interface with one or more Clinical Systems orother systems. For instance, the Expert System may interface with aClinical Data Repository, an individual data system, such as a lab orpharmacy, an interface engine, or other repositories, systems, orengines.

Generally, as used herein, Expert System may not refer to the entirebroad category of expert systems, such as those used in artificialintelligence applications. Rather while the Expert Systems describedherein may incorporate principles of artificial intelligence, an ExpertSystem as used herein is a type of Clinical Decision Support System(CDSS) as that term is understood by those skilled in the art ofmedicine.

The Expert System 119 and the Clinical System 101 may, in someembodiments, comprise one or more special purpose and/or one or moregeneral purpose computers including various computer hardwarecomponents. Aspects of the invention also may be described in terms ofmethods comprising functional steps and/or non-functional acts. Thefollowing is a description of acts and steps that may be performed inpracticing the present invention. Usually, functional steps describe theinvention in terms of results that are accomplished, whereasnon-functional acts describe more specific actions for achieving aparticular result. Although the functional steps and non-functional actsmay be described or claimed in a particular order, the present inventionis not necessarily limited to any particular ordering or combination ofacts and/or steps.

The invention will be described in the general context ofcomputer-executable instructions, such as program modules, beingexecuted by computers in network environments. Generally, programmodules include routines, programs, objects, components, datastructures, etc. that perform particular tasks or implement particularabstract data types. Computer-executable instructions, associated datastructures, and program modules represent examples of the program codemeans for executing steps of the methods disclosed herein. Theparticular sequence of such executable instructions or associated datastructures represents examples of corresponding acts for implementingthe functions described in such steps.

In addition to the above, embodiments of the present invention may alsoinclude computer-readable media for carrying or having thecomputer-executable instructions or data structures stored thereon, suchinstructions of data structures may be computer software code. Suchcomputer-readable media can be any available media that can be accessedby a general purpose or special purpose computer. By way of example, andnot limitation, such computer-readable media can include RAM, ROM,EEPROM, CD-ROM or other optical disc storage, magnetic disk storage orother magnetic storage devices, or any other medium which can be used tocarry or store desired program code means in the form ofcomputer-executable instructions or data structures and which can beaccessed by a general purpose or special purpose computer. Wheninformation is transferred or provided over a network or anothercommunications connection (either hardwired, wireless, or a combinationof hardwired or wireless) to a computer, the computer properly views theconnection as a computer-readable medium. Thus, any such connection isproperly termed a computer-readable medium. Combinations of the aboveshould also be included within the scope of computer-readable media.Computer-executable instructions include, for example, instructions anddata which cause a general purpose computer, special purpose computer,or special purpose processing device to perform a certain function orgroup of functions.

Those skilled in the art will appreciate that the invention may bepracticed in network computing environments with many types of computersystem configurations, including personal computers, hand-held devices,multi-processor systems, microprocessor-based or programmable consumerelectronics, network PCs, minicomputers, mainframe computers, and thelike. The invention may also be practiced in distributed computingenvironments where tasks are performed by local and remote processingdevices that are linked (either by hardwired links, wireless links, orby a combination of hardwired or wireless links) through acommunications network. In a distributed computing environment, programmodules may be located in both local and remote memory storage devices.These computer systems may include various interfaces includingkeyboards, mice, computer monitors, network connections, and the like.

As mentioned above, portions of the Clinical System 101 may beimplemented as computer software code on one or more computer systems.The software code of the Clinical System 101 is a separate applicationwith respect to the software code of the Expert System 119. However,those of skill in the art will appreciate that, although separateapplications, the Expert System 119 and the Clinical System 101 may berunning on a common computer system or network of computer systems.Further, while the Expert System 119 and the Clinical System 101 areseparate systems, embodiments of the invention include interfaces suchas the Expert System Interface Engine 125 for facilitating standardizedcommunications between the Expert System 119 and the Clinical System101. While the Expert System Interface Engine 125 is shown as a separatemodule of the Expert System 119, it should be understood that an ExertSystem Interface may be implemented at any appropriate location. Forexample, an Expert System Interface may be implemented as part of theExpert System Database 124 or at any other suitable location. The ExpertSystem Interface still includes the functionality of the Expert SystemInterface Engine 125 as described herein. Similarly, other moduleswithin the Expert System 119 and Clinical System 101 can be implementedin other locations, within those systems respectively, than those shownin the exemplary drawings while still being within the scope ofembodiments of the present invention.

One exemplary workflow associated with the system of FIG. 1 isillustrated in FIG. 2. With continuing reference to FIGS. 1 and 2, theClinical System 101 generates clinical data “box 201”. Clinical data maybe generated by a physician entering data into the Clinical System 101or one of its modules 130-136 through UI 116. The data can also beobtained from test results, admission and discharge data entered by ahospital admitting department, ordering or providing medications, andthe like. The clinical data may be sent by the Clinical System InterfaceEngine 108 across the Inbound Data Interface 133 “box 202”. The ExpertSystem Interface Engine 125 receives the data from the Inbound DataInterface 133 “box 203”, and processes it. This processing may includeattaching a standard data identifier to data elements in the message,followed by processing by the Expert System Interface Engine 125 withinthe Expert System 119. The processed information may then be storedwithin the Expert System Database 124 for further processing “box 204”.The further processing may be accomplished, for example by a clinicaldecision module 126. In this example, the clinical decision module isshown as software code that is part of the Expert System Database 124.However, the decision module 126 may be implemented in other locationswithin the Expert System 119. The clinical decision module 126 caninclude an inference engine that uses the expert data, i.e., datarepresentative of knowledge in the medical field relating to thediagnosis and treatment of medical conditions stored in the ExpertSystem Database 124, to determine treatment options for a particularpatient based upon the data received from Clinical System 101.

On occasion, the Expert System 119 can also generate an alert “box 205”.This alert may be specific to a patient, and related to some aspect ofclinical care such that the user at any one or all of the UI 116 couldbe notified, for instance, to take an action or with information or dataassociated with patient. This alert can be sent from the Expert System119 via the Expert System Interface Engine 125 to the Clinical System101 via the Outbound Alert Interface 131 “box 206”. This message can bepushed from the Expert System 119 to the Clinical System 101, or it canbe requested or queried by the Clinical System 101. The Clinical System101 receives the alert “box 207” and displays the alert “box 208”through one or more of a variety of display mechanisms, such as one ofthe UI 116, associated with the Clinical System 101. This could includedisplay of an alert message in an inbox or other messaging system withinthe electronic medical record 107. Alerts may also be transmitted topagers, email inboxes, voice messaging services, and the like of apatient's physician or some other individual. Illustratively, the alertmay be displayed in association with a record related to the patient.This record may be any record within the Clinical System 101. Forinstance, the record could be, by way of example, a patient's laboratoryrecord, radiology record, pharmacy record, CDR record, ADT record, etc.A user is able to view this alert, and determine whether to take anyaction.

With continued attention to FIG. 2, if the user determines that they donot want to take any action on the alert, they may dismiss the alert“box 209”. Doing so may require the user to provide a reason fordismissal, which is documented into the Clinical System 101 “box 210”.The Clinical System 101 updates its audit log appropriately “box 211”.When the alert is dismissed, the Clinical System 101 also sends an auditinformation message to the Expert System 119 via the Audit ActionInterface 136 “box 212”. The audit information message is received bythe Expert System Interface Engine 125 “box 213”. The audit informationmessage contains information to allow the Expert System 119 to updateits audit log as well “box 214”.

When the user determines that they wish to take further actions on thealert, the workflow illustrated in FIG. 3 may be followed. FIG. 3includes boxes 201 through 208 which represent the same actions andfunctions performed and shown with those designations in FIG. 2. Thefollowing description describes, in conjunction with FIG. 3, actions andfunctions performed when a user decides to take further actions on analert as opposed to simply dismissing the alert as was illustrated inFIG. 2. With reference to FIGS. 1 and 3, the user is allowed to accessthe Expert System 119 by selecting a link or similar mechanism withinthe user interface UI 116 of the Clinical System 101 “box 309”. Forexample, the Clinical System 101 may provide a user interface 116 thatincludes links such as hyperlinks, buttons, radio buttons, pull-downmenus, lists and the like. A link such as one of these may be tied tothe Expert System 119. Selecting this link provides the user access tothe alert within the Expert System 119. Namely, the Clinical SystemInterface Engine 108 requests access from the Expert System 119 (box310). The request is sent via the Inbound Application Interface 132 andreceived by the Expert System Interface Engine 125 “box 311”. Therequest contains information to allow the Expert System 119 to displaythe data associated to the correct alert “box 312”, while maintainingpatient and user context provided by the Clinical System 101. Forinstance, the same frame of a User Interface 116 can contain data thatis stored at the Clinical System 101 and data received from the ExpertSystem 119. Alternatively, selecting the link can initiate a “pop-up”window within the application opening at the Clinical System 101 thatcontains the data associated with the alert.

In either case, the user is now able to work within the Expert System119, through one of the UI 116 at the Clinical System 101 to manage thealert “box 313”. Managing the alert, may include the user updatingclinical data “box 314”. The user may wish to enter additional patientinformation that is needed to complete processing or managing the alert.As a result of processing or managing the alert, the Expert System 119itself may also generate patient information or inferences concerningthe patient. If this information is clinical information that can bestored in the clinical systems, such as height, weight, diagnosis, orother clinical data, the Expert System Interface Engine 125 can sendthis clinical data “box 315” such that is received by the ClinicalSystem Interface Engine 108 “box 316” via the Outbound Data Interface134. The Clinical System 101 can then process and store “box 317” thisnew clinical data according to its design.

As an outcome of the alert and processing and managing the alert, theuser may wish to place orders “box 318” to be applied to the patient.These orders may include diagnostic studies or testing, or adding,modifying, or discontinuing medication or other orders. Any new orderscan be sent using the Expert System Interface Engine 125 “box 318” tothe external Clinical System 101 “box 320” using the Outbound OrdersInterface (OOI) 135. The Clinical System (CS) 101 then processes the neworders “box 321” by the Clinical System Interface Engine 108 deliveringthe new order(s) to the clinical module(s) that are to receive suchorder(s).

Upon completion of managing and processing the alert, the outcome of thealert and any actions taken by the Clinical System 101 can be updated inthe Expert System 119 and its audit log “box 322”. Following updating,an audit info message is sent to the Clinical System 101 “box 323” viathe Audit Action Interface 136. This audit info message can contain alog of actions taken and any reasons the user of the Clinical System 101has entered for these actions. When the audit info message is receivedby the Clinical System Interface Engine 108 “box 324”, the ClinicalSystem 101 can updates its own audit logs appropriately “box 325”. Theuser can be returned to the Clinical System 101 from the Expert System119.

Another exemplary embodiment of the present invention is shown inschematic form in FIG. 4. The embodiment shown in FIG. 4 illustrates anExpert System 419 coupled to a Clinical System 401, and other clinicalmodules including a Clinical Data Repository 402 and a pharmacy system417. Alternatively, the pharmacy system 417 may be some other suitabledepartmental system. Notably, as used herein, a clinical system mayrefer to a collection of clinical modules. A clinical system may alsorefer to a collection of smaller clinical systems, or any combination ofsmaller clinical systems and clinical modules. Those skilled in the artunderstand that the clinical modules shown herein are often referred toas clinical systems. The term clinical modules is used to illustrate aseparate nature of smaller clinical systems within a collection ofclinical systems, or to illustrate a separate nature of smaller clinicalsystems from other clinical systems. Thus, a clinical system mayactually be comprised of other clinical systems. The Expert System 419is connected to the Clinical System 401, Clinical Data Repository 402and pharmacy 417 systems via data feeds 430, 432, 433, 434, 435 a, 435 b436, similar to the data feeds 130, 132, 133, 134, 135 136 shown in FIG.1.

Three exemplary workflows within this embodiment are illustrated inFIGS. 5, 6, and 7. With attention now directed to FIGS. 4 and 5, in FIG.5, a clinician can use a Clinical System 401 to create or modify ordersfor a patient “box 501”. The Clinical System 401 can generate a requestfor processing by the Expert System 419 (box 502). The new order, asdescribed above in the interface description, can be sent to the ExpertSystem 419 via the Synchronous Alert Interface 430. The message sent onthe Synchronous Alert Interface 430 may contain user and patientidentifiers, as well as the new order and other order details such asdose, route, frequency, and duration. The message may also contain otherdetails to aid in evaluating the order within the Expert System 419. Thenew order message is sent synchronously, meaning that further processingof the order within the Clinical System 401 is halted until a reply isreceived from the Expert System 419. Upon receipt of this message, theExpert System 419 can immediately process the contents of the message“box 503”, and send its reply “box 504” back to the Clinical System 401via the Synchronous Alert Interface 430. This reply message can containan indication of whether an alert was generated. If no alert wasgenerated “box 505”, the Clinical System 401 can continue its processing“box 506” by sending the order request to the appropriate clinicalmodule.

With attention now directed to FIGS. 4, 6, and 7, again, a clinicianuses a Clinical System 401 to create or modify orders for a patient“boxes 601, 701”. The Clinical System 401 requests the Expert System 419to process the orders “boxes 602, 702”. The Expert System 419 processesthe proposed order “boxes 603, 703”, as described above. In theseexamples, an alert is generated. The reply from the Expert System 419“boxes 604, 704” can contain information about the nature of the alert,Similar to other alerts generated by the Expert Systems 419 of thepresent invention. It may contain specific patient and user information,as well as a detailed recommendation, such as, but not limited to, asuggestion to discontinue an order or to place an order for a specificmedication. The reply may contain any or all of the details to generatethe order in the Clinical System 401. The reply may also contain linkinformation, such a link address that can be displayed to and accessibleby the clinician, physician, or other individual through user interface(such as the UI 116 FIG. 1) on the Clinical System 401. This linkenables the user to access the Expert System 419 directly from theClinical System 401 by initiating a call through the Inbound ApplicationInterface 432. The Clinical System 401 displays the alert to the user“boxes 605, 705”, such as by displaying a message in a user interface UI116 on the Clinical System 401, to allow the user to act upon it.

Continuing the illustrative process, in FIG. 6, the user may determinethat the alert is not appropriate, or otherwise decide to dismiss thealert “box 606”. The Clinical System 401 provides a resource to dismissthe alert and to capture any reason given by the user for dismissing thealert. For instance, the Clinical System 401 may present a userinterface that includes a link or button through which a user maydismiss the alert and a textbox to provide reasons for such dismissal.This information associated with the dismissal of the alert may be usedto update the audit log of the Clinical System 401 “box 607”. Inaddition, the Clinical System 401 can send a message containing auditinformation to the Expert System 419 via the Audit Action Interface 436“box 608”. This permits the Expert System 419 to receive the auditinformation “box 609” and to update its audit log appropriately “box610”.

Alternatively to the process described in FIG. 6, the user may determinethat the alert is appropriate, and decide to take one or morerecommended actions, as illustrated in FIG. 7. These actions may begenerated within the Clinical System 401. In the example shown in FIG.7, the user may add or change orders “box 706”. These additions orchanges can be made using the Expert Systems 419, the Clinical System401, or the associated clinical modules. Upon completion of the takenactions, the Clinical System 401 updates its audit log “box 707”. Inaddition, the Clinical System sends a message containing auditinformation detailing the actions taken to the Expert System 419 “box708” via the Audit Action Interface 436 “box 708”. This permits theExpert System 419 to receive the audit information “box 709” and toupdate its audit log appropriately “box 710”.

Yet another exemplary embodiment is shown in schematic form in FIG. 8.FIG. 8 illustrates an Expert System 819 that includes an Expert SystemUser Interface an Expert System Database 824 and an Expert SystemInterface Engine 825 interconnected by various data feeds 820, 821, 822similar to the data feeds 120, 121 122 in FIG. 1.

The Expert System 819 is connected via the Expert System InterfaceEngine 825 and various data feeds 833, 834, 835 similar to the datafeeds 133, 134, 135 in FIG. 1 to a Clinical System 801. The ExpertSystem 819 may be similar to other expert systems described herein suchas the Expert System 119 in FIG. 1. A possible workflow for thisembodiment is illustrated in FIG. 9. With attention now directed towardsFIGS. 8 and 9, in this example, the user accesses the Expert System 819directly via the Expert System User Interface 823 “box 901”. Because theInbound Data Interface 833 provides a feed of patient identificationinformation and patient data, the user is able to select a specificpatient within the Expert System 819 “box 902”. Alternatively, theExpert System 819 may, through its processing, generate alerts which arepresented within the Expert System User Interface 823. The user mayaccess data specific to the selected patients through selecting thesealerts. Alternatively, the user may query the Expert System 819 throughits User Interface 823 for patients meeting specified criteria, and maythen access specific patient identification information and data throughthe results of this query. The query returns a list of patients meetingthe specified criteria. The user may then select patients from thereturned list to access patient information. The query may be formulatedin the User Interface 823, by using for example, menus, drop-down menus,data fields, text boxes and the like. In yet another alternativeembodiment, the Expert System 819 may present the user with lists orrosters of patients, from which a specific patient may be identified sothat information can be accessed through its User Interface 823. Therosters or lists may be lists based on patient location, clinicalservice, attending or consulting physician, or other patient listsmaintained within the clinical system. They are displayed in the ExpertSystem 819 such as by displaying in the User Interface 823. The user mayselect a patient from the roster or list. In yet another alternativeembodiment, the Expert System 819 may present a patient-specific view ofclinical information, such as a summary or rounds report for a givenphysician, clinician, clinic, department, etc. within its User Interface823, through which a user may access data specific to the selectedpatient.

Once the user has accessed data associated with a specific patient, theuser may then use the expert knowledge contained in the knowledge baseof the Expert System 819 to generate patient-specific recommendations“box 903” for therapy or for further evaluation. The user is able toselect specific orders “box 904” that are then sent to the ClinicalSystem 801 “box 905” through the ESIE 825 via the Outbound OrdersInterface 835. The Outbound Order Interface 835 may communicate with theClinical System 801 via the Clinical System Interface Engine or directlywith an orders application within the Clinical System 801. In the latterinstance the Expert System Interface Engine 825 sends the orders acrossthe Outbound Order Interface directly to the orders application, or someother clinical module, within the Clinical System 801 (box 905). Theorders application then receives the orders “box 912” and may thencomplete any necessary processing of the order “box 913”. The ClinicalSystem 801 receives “box 906” and processes the orders “box 907”. If theuser entered clinical data for the patient that could be stored withinthe Clinical System 801 or the Expert System 819 generated such datafrom its processing, this may be sent to the Clinical System via theOutbound Data Interface.

An optional feature of an exemplary expert system is a mechanism tostandardize data and vocabulary terms between the expert system and theclinical system. In one configuration, a Vocabulary Server is part ofthe Expert System. The vocabulary server includes modules or softwarethat assigns a vocabulary term to a data element. In one embodiment ofthe invention, the identifiers for data elements within the ClinicalSystem are initially mapped to standard nomenclatures. All data elementswhich are received from the Clinical System are stored with standardnomenclature identifiers attached within the Expert System database,based upon this mapping. For data elements which are not mappedinitially, there may be functionality in the Vocabulary Server whichallows the system to identify the best match to a standard nomenclatureidentifier. This allows a system to attach a standard identifier to eachof one or more data elements that may have different identifiers basedon their generation in their originating systems, but which in factrepresent the same entity. In an exemplary embodiment, this VocabularyServer is a component of the Expert System Interface Engine. As eachinbound data element is received from the Clinical Systems, theVocabulary Server attaches a standard identifier to the received data.As each outbound data element is written to a message to be sent out ofthe Expert System Interface Engine, the Vocabulary Server assigns theappropriate external identifier based on the standard identifier that isattached by utilizing the above mapping of Expert System nomenclatureidentifiers to the Clinical System data elements.

In another configuration, the Vocabulary Server is a component of theClinical System Interface Engine. As each data element is sent to theExpert System Interface Engine, a standard identifier is applied. Thereverse is performed on data sent to the Clinical System InterfaceEngine, as standard identifiers received are mapped to localidentifiers.

In yet another configuration, the data standardization is a dynamicprocess within the Expert System. Data elements are stored as they aresent in through the interface. As the data elements are accessed by theExpert System, the Vocabulary Server maps each element to a standardidentifier to be used in the Expert System processing.

In yet another configuration, the data elements in the Clinical Systemsare all stored with standard identifiers, and these identifiers are sentthrough the interfaces. No additional mapping is performed by theinterfaces, nor by the Expert System itself. In this instance, the useof data and vocabulary standards throughout both the Clinical System andthe Expert System removes the need for a Vocabulary Server.

Vocabulary Servers may be implemented by custom design. However,Vocabulary Servers may also be implemented in embodiments of theinvention by using a commercially available Vocabulary Server. Suchservers are readily available from Health Language Inc. of Aurora, Colo.and Apelon Inc. of Ridgefield, Conn.

The present invention may be embodied in other specific forms withoutdeparting from its spirit or essential characteristics. The describedembodiments are to be considered in all respects only as illustrativeand not restrictive. The scope of the invention is, therefore, indicatedby the appended claims rather than by the foregoing description. Allchanges that come within the meaning and range of equivalency of theclaims are to be embraced within their scope.

1. A computer program product for use in a system where a separateexpert system is configured to communicate with a clinical system havingone or more clinical modules, and notwithstanding that the separateexpert system and the clinical system are configured to process datahaving different and otherwise incompatible data formats, the computerprogram product for implementing a method of interfacing the separateexpert system with the clinical system, the computer program productcomprising one or more physical storage media have stored thereoncomputer-executable instructions that, when executed at a processor,cause the system to perform the method, including the following: receiveclinical data from the clinical system on at least one of an inbounddata interface and a synchronous alert interface, the clinical datahaving a first format structured for compatible processing at theclinical system; modify the structure of the clinical data to a seconddifferent format structured for compatible processing at the separateexpert system such that the clinical data can be compatibly processed atthe separate expert system, wherein without the structural modificationof the clinical data the separate expert system is unable to compatiblyprocess the clinical data; store the modified clinical data in an expertsystem database of the expert system in the second different format;process the modified clinical data in the expert system to make amedical decision; generate an alert based on results of processing themodified clinical data, the alert having the second different dataformat structured for compatible processing at the separate expertsystem; modify the structure of the generated alert to the first formatsuch that the generated alert can be compatible processed at theclinical system, wherein without the structural modification of thegenerated alert the clinical system is unable to compatibly process thealert; and send the modified generated alert to the clinical system onat least one of the synchronous alert interface and the outbound alertinterface.
 2. The computer program product of claim 1, furthercomprising computer-executable instructions that, when executed, causethe computer system to: receive audit information on an audit actioninterface from the clinical system when the alert has been dismissed atthe clinical system; and update an audit log in the expert system. 3.The computer program product of claim 1, further comprisingcomputer-executable instructions that, when executed, cause the computersystem to: receive a request on at least one of a synchronous alertinterface and an inbound application interface from the clinical systemfor access to the expert system; display the alert from the expertsystem at the clinical system; receive an update of clinical data on atleast one of a synchronous alert interface, an inbound applicationinterface and an inbound data interface from a user at the clinicalsystem; and send the update of clinical data to the clinical systemusing at least one of the synchronous alert interface and the outbounddata interface.
 4. The computer program product of claim 3, furthercomprising computer-executable instructions that, when executed, causethe computer system to update an audit log at the expert system.
 5. Thecomputer program product of claim 3, further comprisingcomputer-executable instructions that, when executed, cause the computersystem to: receive an order; and send the order to a clinical module. 6.The computer program product of claim 5, further comprisingcomputer-executable instructions that, when executed, cause the computersystem to update an audit log at the expert system.
 7. The computerprogram product of claim 1, wherein computer-executable instructionsthat, when executed, cause the computer system to send the modifiedgenerated alert to the clinical system comprise computer-executableinstructions that, when executed, cause the computer system to push thealert from the expert system.
 8. The computer program product of claim1, wherein computer-executable instructions that, when executed, causethe computer system to send the modified generated alert to the clinicalsystem comprise computer-executable instructions that, when executed,cause the computer system to: receive a request or query from theclinical system; and send the alert to the clinical system in responseto the request or query.
 9. The computer program product of claim 1,wherein computer-executable instructions that, when executed, cause thecomputer system to generate an alert based on results of processing themodified clinical data comprise computer-executable instructions that,when executed, cause the computer system to generate an alert thatcomprises data elements and further comprising: computer-executableinstructions that, when executed, cause the computer system to attachstandard identifiers to at least a portion of the data elements.
 10. Thecomputer program product of claim 1, further comprisingcomputer-executable instructions that, when executed, cause the computersystem to structure messages including the modified generated alertaccording to proprietary message definitions.
 11. The computer programproduct of claim 1, further comprising computer-executable instructionsthat, when executed, cause the computer system to structure messagesincluding the modified generated alert according to industry standardmessage definitions.
 12. The computer program product of claim 11,wherein computer-executable instructions that, when executed, cause thecomputer system to structure messages including the modified generatedalert according to industry standard message definitions comprisecomputer-executable instructions that, when executed, cause the computersystem to structure messages including the modified generated alertaccording to the HL7 protocol.
 13. The computer program product of claim1, wherein computer-executable instructions that, when executed, causethe computer system to receive clinical data from the clinical systemcomprise computer-executable instructions that, when executed, cause thecomputer system to receive clinical data from an interface enginedisposed on a clinical module within the clinical system.
 14. A computerprogram product for use at an expert system separate from a clinicalsystem and configured to communicate with the clinical system, thecomputer program product for implementing a method of providing clinicaldecision support, notwithstanding that the separate expert system andthe clinical system are configured to process data having different andotherwise incompatible data formats, the computer program productcomprising one or more physical storage media have stored thereoncomputer-executable instructions that, when executed at a processor,cause the system to perform the method, including the following: receivean order on at least one of a synchronous alert interface and an inbounddata interface, from the clinical system, the order having a firstformat structured for compatible processing at the clinical system;modify the structure of the order to a second different formatstructured for compatible processing at the separate expert system suchthat the order can be compatibly processed at the separate expertsystem, wherein without the structural modification of the order theseparate expert system is unable to compatibly process the order;process the modified order to generate a response to the order, theresponse having the second different data format structured forcompatible processing at the separate expert system; modify thestructure of the response to the first format such that the response canbe compatible processed at the clinical system, wherein without thestructural modification of the response the clinical system is unable tocompatibly process the response; and send the modified response to theclinical system on at least one of the synchronous alert interface, anoutbound data interface and an outbound orders interface.
 15. Thecomputer program product of claim 14, wherein computer-executableinstructions that, when executed, cause the computer system to processthe modified order to generate a response to the order comprisecomputer-executable instructions that, when executed, cause the computersystem to generate a response that is an alert, and further comprisingcomputer-executable instructions that, when executed, cause the computersystem to: receive audit information from the clinical system on atleast one of a inbound audit interface, inbound data interface, and anaudit action alert interface when the alert has been dismissed at theclinical system; and update an audit log in the expert system.
 16. Thecomputer program product of claim 14, wherein computer-executableinstructions that, when executed, cause the computer system to processthe modified order to generate a response to the order comprisecomputer-executable instructions that, when executed, cause the computersystem to generate a response that is an alert, and further comprisingcomputer-executable instructions that, when executed, cause the computersystem to: receive audit information from the clinical system on atleast one of a inbound audit interface, inbound data interface and anaudit action alert interface when the alert results in an addition orchange to the orders at the clinical system; and update an audit log inthe expert system.
 17. The computer program product of claim 14, whereincomputer-executable instructions that, when executed, cause the computersystem to receive an order comprise computer-executable instructionsthat, when executed, cause the computer system to receive and order thatincludes data elements, and further comprising computer-executableinstructions that, when executed, cause the computer system to assignstandard identifiers to at least a portion of the data elements.
 18. Thecomputer program product of claim 14, further comprisingcomputer-executable instructions that, when executed, cause the computersystem to structure messages including the modified response accordingto proprietary message definitions.
 19. The computer program product ofclaim 14, further comprising computer-executable instructions that, whenexecuted, cause the computer system to structure messages including themodified response according to industry standard message definitions.20. The computer program product of claim 19, whereincomputer-executable instructions that, when executed, cause the computersystem to structure messages including the modified response accordingto industry standard message definitions comprise computer-executableinstructions that, when executed, cause the computer system to structuremessages including the modified response according to the HL7 protocol.21. A computer program product for use at an expert system separate froma clinical system and configured to communicate with the clinicalsystem, the computer program product for implementing a method ofproviding clinical decision support, notwithstanding that the separateexpert system and the clinical system are configured to process datahaving different and otherwise incompatible data formats, the computerprogram product comprising one or more physical storage media havestored thereon computer-executable instructions that, when executed at aprocessor, cause the system to perform the method, including thefollowing: allow access to an expert system user interface; provide anelement in the expert system user interface for selecting at least onepatient from patients in a clinical system; generate a patient specificrecommendation; receiving orders from a user accessing the expert systemuser interface, the order having a first format structured forcompatible processing at the expert system; process the order togenerate a response to the order, the response having the first dataformat structured for compatible processing at the separate expertsystem; modify the structure of the response to a second differentformat such that the response can be compatible processed at theclinical system, wherein without the structural modification of theresponse the clinical system is unable to compatibly process theresponse; and send the modified response to the clinical system on atleast one of the synchronous alert interface, an outbound data interfaceand an outbound orders interface.
 22. The computer program product ofclaim 21, further comprising computer-executable instructions that, whenexecuted at a processor, cause the system to: receive updates toclinical data from a user accessing the expert system user interface;and send the updates to the clinical system on an outbound datainterface.
 23. The computer program product of claim 22, whereincomputer-executable instructions that, when executed at a processor,cause the system to send the updates to the clinical system comprisecomputer-executable instructions that, when executed at a processor,cause the system to send the updates directly to a clinical modulewithin the clinical system.
 24. The computer program product of claim22, wherein computer-executable instructions that, when executed at aprocessor, cause the system to send the updates comprisecomputer-executable instructions that, when executed at a processor,cause the system to send the updates to a clinical system interfaceengine for delivery to a clinical module within the clinical system. 25.The computer program product of claim 21, wherein computer-executableinstructions that, when executed at a processor, cause the system toprovide an element in the expert system user interface comprisecomputer-executable instructions that, when executed at a processor,cause the system to provide an element in the expert system userinterface for selecting at least one patient from at least one of a listof patients, an alert, or a query.
 26. The computer program product ofclaim 21, further comprising computer-executable instructions that, whenexecuted, cause the computer system to structure messages including themodified response according to proprietary message definitions.
 27. Thecomputer program product of claim 21, further comprisingcomputer-executable instructions that, when executed, cause the computersystem to structure messages including the modified response accordingto industry standard message definitions.
 28. The computer programproduct of claim 21, wherein computer-executable instructions that, whenexecuted, cause the computer system to structure messages including themodified response according to industry standard message definitionscomprise computer-executable instructions that, when executed, cause thecomputer system to structure messages including the modified responseaccording to the HL7 protocol.